SCCMPod-578 PCCM: Reducing Pediatric Sepsis Mortality in Ghana

Dr. Mack: Hello and welcome to the Society of Critical Care Medicine podcast. I'm your host, Dr. Elizabeth Mack. Today, I'm speaking with Dr. Vanessa Denny, MD, MS, and Dr. Justicia Amisah, MD, about the article, Pediatric Emergency Department Care for Septic Shock in Sub-Saharan Africa, Single-Center Outcomes Before versus After Implementation of a Telesimulation Program in 2023 to 2024. This was published in the July 2026 issue of Pediatric Critical Care Medicine. To access the full article, visit pccmjournal.org. Dr. Denny is a pediatric critical care attending physician at the Children's Hospital of Philadelphia. Her academic and clinical work centers on advancing pediatric critical care delivery in international and resource-limited settings. She has led and participated in global health initiatives across the Caribbean, Central America, and Sub-Saharan Africa. Her current research focuses on implementing an innovative telesimulation training program to improve outcomes in pediatric septic shock in Sub-Saharan Africa, as well as developing sustainable, low-bandwidth PICU teleconsultation systems to expand access to pediatric critical care expertise in underserved regions.

Dr. Amisah is a pediatric resident and clinical research at the Kung Fu Inochi Teaching Hospital in Kumasi, Ghana. She co-authored notable studies on pediatric emergency care, healthcare barriers for septic children, and telesimulation septic shock training programs in low-resource settings. Welcome.

Dr. Amisah: Thank you so much, Dr. Mack. We're excited to be here and talk about our work.

Dr. Denny: Thank you, Elizabeth, for having us.

Dr. Mack: And before we start, do you have any disclosures to report?

Dr. Amisah: No disclosures.

Dr. Denny: No disclosures.

Dr. Mack: Thank you so much for this important contribution to the literature. I'd love to hear a little bit about how this collaboration came about and where the idea for the study originated.

Dr. Amisah: Yes. Thanks, Dr. Mack. My relationship with Kung Fu Inochi actually goes back quite a long way.

I was initially introduced to Dr. John Appiah, who was our local Ghanaian PI of the project when I was a medical student. And I spent several of my medical school breaks working with him at the hospital. And I was shortly then introduced to Justicia.

So this project really grew out of a longstanding partnership rather than coming in with a study idea and looking for a site. And then when I started my fellowship program at CHOP, I really wanted to bring together my interest in global health and critical care to pursue my academic research work. So we performed an audit at the hospital Kung Fu Inochi, and we looked at children who presented with septic or septic shock.

And what really struck us at the time was the extraordinarily high mortality rates at this hospital. And a lot of these children were dying very early in their hospitalization. So before we designed this intervention, we really wanted to understand why.

Why was this happening? So we initially conducted a needs assessment qualitative study, which we also published a couple of years ago with the caregivers and the frontline clinicians to understand why children were dying with such a high mortality rate at this hospital. We identified barriers at multiple levels from delays in accessing care, limited resources, to a very clear request from a lot of the providers for additional training and recognizing and managing sepsis.

So all of that led us to whether we would be able to create something that was practical and inexpensive and sustainable for this specific environment. So through our collaborators at CHOP, at Penn, at Kung Fu Inochi, we adapted what we found to be called the Annenberg Hot Keys, which is a low bandwidth tele-simulation platform. And this ultimately became the foundation of our REACH program.

Dr. Mack: Awesome. Can you share a bit about the differences in the setting at Kung Fu Inochi? What resources are available?

What's not available? I'd love to hear a little bit more about the setting you're working with.

Dr. Denny: Okay. Thank you for the question. So Kung Fu Inochi is a teaching hospital.

It's a tertiary center, actually the second largest hospital in Ghana. And it has a substantial pool of specialist expertise. And when it comes to pediatrics, there's a wide range of pediatric subspecialties.

However, one of our major challenges is the fact that there isn't much infrastructure and capacity. So for instance, we have a 15-bed pediatric emergency unit and a four-bed PICU. So it serves as a referral center for about 10 of the 16 regions that we have in Ghana.

So given the high volume of patients that we receive, there's a demand for our services. And most of the time, it exceeds our available capacity. So we do have essential critical care equipment.

We have mechanical ventilators, high-flow nasal cannula systems. We have patient monitors, just to mention a few. But unfortunately, the number of critically ill children that require support exceed what we have available.

So while we have the specialist expertise and some essential equipment to work with, there still remains a significant gap between the volume of cases that we receive and the infrastructure that we have to manage these cases.

Dr. Mack: Wonderful. Thank you so much. I think that's incredibly helpful.

What would you say are the biggest contributors to that 50% baseline mortality rate of pediatric sepsis and septic shock that you referenced in the manuscript?

Dr. Denny: So the high baseline mortality is actually multifactorial. One of the major contributors for that is the delayed recognition by healthcare providers. And that's partly due to the fact that there are a lot of gaps in the training and the capacity that we have.

We know that when it comes to pediatric sepsis, every hour matters. However, if the healthcare givers are unable to recognize sepsis early and initiate the treatment promptly, then we are going to be dealing with an advanced organ dysfunction rather than a potentially reversible sepsis. Another factor is delayed presentation and referral.

This particularly is influenced by challenges with our referral system, financial constraints by the caregivers, and gaps in our local healthcare health insurance coverage. There's also the fact that there's resource and capacity limitation, as I talked about earlier. So even though we have the essential equipment, we don't have access to advanced critical care therapies such as ECMO.

And there are also challenges with timely access to certain investigations, blood products, and sometimes antibiotics. So all these things come together to give us that high mortality, more than 50% that we started with.

Dr. Mack: Thank you so much. I'd love to hear a bit about what you all did in terms of the actual telesimulation itself with the ED providers. And I was particularly intrigued by the utilization of videos of the Ghanian kids.

So would love to hear a bit more.

Dr. Amisah: Yes, of course. So one thing that was really, really important to me and the team was that we didn't want to create a simulation in Philadelphia and then just simply export it to Ghana. We developed this module specifically for Confo Noce.

So with caregiver consent, we recorded videos of the Ghanian children at different stages of sepsis and septic shock, and ultimately created like 23 short video clips. This simulation, it works almost like a choose your own adventure. So providers assess the child and decide what they want to do.

Give oxygen, obtain IV access, give fluids or antibiotics. And then we show them how the patient responds based on those decisions. The sessions included a brief pre-brief, which was about 15 minutes, a 20 minute scenario, and then a structured debrief session, usually with three to five providers at a time.

Because the videos were all locally stored and the platform requires very little bandwidth, we were able to facilitate the training remotely without sophisticated simulation equipment or high speed internet. I think that contextualization was one of the most important components of this research study. Providers repeatedly told us that the scenario felt relevant to them because they were seeing patients and populations that they serve and challenges that reflected their actual practice environment.

Dr. Mack: Fascinating. Thank you so much. I can imagine that was particularly important.

Just curious, were these scenarios co-developed?

Dr. Amisah: Yes, a hundred percent. We had a lot of input from our colleagues at the Confuente Hospital who refined all of our scenarios and simulations and really co-developed the whole program.

Dr. Mack: Wonderful. And if you could, we'd love to hear a bit about the actual intervention itself. I know you shared the debrief in real time, specifically kind of honing in on the teamwork aspect, the fluids management reassessment.

What did it look like?

Dr. Amisah: Yes. The technology was really only one part of the intervention. Much of the educational value came from the debriefing sessions.

We focused on the fundamentals of early shock management, recognizing abnormal perfusion, obtaining vascular access, giving oxygen and antibiotics, making thoughtful decisions about fluids, especially in a low resource environment where you may only have one or two ventilators available, and importantly, reassessing after every intervention. We also trained providers as teams because resuscitation depends on communication, role allocation, and someone continually stepping back to reassess the patient. For fluid management, we were intentionally contextual to Confuente.

We weren't just teaching that every child automatically needs a certain amount of fluid. We really emphasize that giving fluid when appropriate and then asking, did it work and should I give more? Interestingly, after the intervention, fewer children received fluid boluses, but every child who did receive a fluid was reassessed.

I think that's an important message. Better substance care doesn't necessarily mean doing more. It means making deliberate decisions and assessing whether what you did actually worked.

Dr. Mack: Great. Sounds relevant for all of us. I would love to hear a bit about the results and your thoughts on reasons why the mortality decreased, which is wonderful.

Dr. Denny: Right. For our results, more children received oxygen when it was indicated, and IV access was secured faster post-intervention. We also saw that less children received fluid boluses, while most importantly, all the children that received a fluid bolus were reassessed afterwards.

We also observed that there was an improvement in the time taken to collect blood cultures, and there was a substantial reduction in mortality. Pre-intervention was 36%, and post-intervention, it dropped to 10%. The combination of the early recognition, the timely interventions that were put in place, all contributed to that substantial mortality drop, 36% to 10%.

Dr. Mack: Incredible. Thank you so much. Any thoughts on why the time to initial physician assessment increased?

Dr. Denny: So I think that the increase in time to the initial physician assessments may actually reflect a more thorough and thoughtful clinical evaluation process. I don't think that necessarily means that the care was delayed, but in our debriefing, we emphasized a thorough assessment, capillary refill time, and reassessments. So that was rather the reason why the time to initial physician assessments actually increased, and not because there was a delay in assessing the child's clinical status.

Dr. Mack: Great. Well, as you all know, sepsis definitions are evolving. I would love to hear your thoughts for any of our listeners who might be wondering how the Phoenix criteria might relate to your work.

Dr. Amisah: Yeah, I think this is a really important question. The Phoenix criteria is an important step forward because they move us away from the SERS definition and toward what we really care about clinically, life-threatening organ dysfunction that's associated with an infection. It also gives us a more standardized definition, which is really helpful for research and for comparing sepsis outcomes across different hospital systems and countries.

The challenge is applying this criteria to lower resource settings. Some of the variables used to characterize organ dysfunction rely on laboratory testing or monitoring that may not be consistently or rapidly available in our settings that we're working in. And importantly, Phoenix wasn't designed as an early screening tool.

In places like Confluenoche, where children may already present late and critically ill, we can't wait for laboratory results or for a child to accumulate enough organ dysfunction to recognize that they're deteriorating. So I really think an important next step is to understand how the Phoenix criteria performs across different resource settings and how we compare standardized definitions with simple but clinically-based approaches to early recognition that are feasible at the bedside for all resource settings.

Dr. Mack: Great. Thank you so much. And along those lines, particularly for your work, the idea of really spreading at scale is exciting.

So a free platform with low bandwidth. Just curious, I'm sure you've thought a bit about what it would take to scale this and any preliminary thoughts on where to next?

Dr. Denny: Yeah. So to scale it effectively, what we'll need is to build the capacity of the local healthcare providers to become facilitators so that the training is not dependent on an external team. And we also need institutional support so that if the telesimulation can be incorporated into our continuing professional development and orientation programs, it can become part of our routine practice rather than a one-off intervention.

Wonderful.

Dr. Mack: Any thoughts on next steps for this work, either at Confluenoche or elsewhere or locally?

Dr. Denny: So for us at Confluenoche, one step we'd like to take is to take this telesimulation program beyond the tertiary center at Confluenoche and incorporate it into the districts and regional hospitals in the Ashanti region, where many of the children with sepsis are first seen. So the goal of this is to equip the healthcare workers at these levels with the knowledge, with the confidence to be able to recognize sepsis and septic shock, to recognize it early and initiate the appropriate intervention and identify the children who require urgent referral to Confluenoche. So by strengthening this care at the first point of contact at the district hospitals, at the regional hospitals, we hope to intervene before significant organ dysfunction develops.

Dr. Mack: Great. Thank you so much. Anything else that we haven't discussed that you'd like to share?

Dr. Amisah: Yes. I just like, you know, first off, I want to thank all of our colleagues at Confluenoche and within the Kumasi Ashanti region who helped us with this project and all of those who took part of it at CHOP and at UPenn. I think the biggest message is that this really isn't a story about technology.

It's a story about contextualization and partnership, which made this so successful and great collaboration. In global health, rather than asking how do we bring what works here somewhere else, I really think we should ask what are the barriers in this particular health system and how can we work with those delivering the care to develop something that works within their environment. The technology itself was simple.

It was free, low bandwidth, and the videos could be recorded with a simple phone. What made it meaningful was that the patients were Ghanaian children, so they represented the population that the clinicians were actually seeing and treating. The setting was familiar and the teaching addressed problems that the providers themselves had identified.

If an inexpensive intervention like this can help clinicians deliver time-critical care more reliably and can ultimately be locally owned and sustained, I think that this has tremendous potential well beyond one hospital or even one disease process.

Dr. Mack: Wonderful. Thank you so much. This concludes another episode of the Society of Critical Care Medicine podcast.

If you're listening on your favorite podcast app and you like what you heard, consider rating and leaving a review. For the Society of Critical Care Medicine podcast, I'm Elizabeth Mack.

Announcer: Elizabeth H. Mack, MD, MS, FCCM, is a professor of pediatrics and chief of pediatric critical care at Medical University of South Carolina, Children's Health in Charleston, South Carolina. Join or renew your membership with SCCM, the only multi-professional society dedicated exclusively to the advancement of critical care.

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